Relatedness and Relationships in Mental Health

London South Bank University

University of Birmingham

SMALL GROUP PROJECT: JULY 2015 – JUNE 2016

The Research Idea

A feeling of connection is fundamental for a flourishing life. Humans need to belong; we need frequent, positively valenced interactions with others, and at least one strong, stable and reciprocal relationship characterised by care and concern (Baumeister & Leary, 1995). If deprived of either of these, individuals are more likely to be unhappy, lonely, and stressed, and risk increased physical and mental health problems and suicide (Baumeister & Leary, 1995). Yet in the context of mental health, relationships are dually implicated in
both “the creation and amelioration of mental health problems” (Pilgrim, Rogers & Bentall, 2009, p.235).

However, contemporary capitalist constructions of the self, as individualist and independent, and biomedical models that construct mental illness as the result of biological processes in discreet organisms, fail to take connectedness into account. This ‘internalism’ (Broome & Bortolotti, 2010), neglects the relational context of distress and wellbeing, and has resulted in a narrow, diagnostically-led focus on the individual in mental health services and polices (Pilgrim et al., 2009).

This research project will bring together scholars from a range of disciplinary perspectives (psychology, philosophy, psychiatry, sociology) to reclaim and foreground relatedness as a central concern for mental health and wellbeing. Through collaborative workshops, we will explore three apparent paradoxes. We plan to also invite further scholars from a range of disciplines to join us for specific workshops. We will culminate our work with a public event, attended by service-users, clinicians and policy makers, to examine the clinical and personal implications of our findings.

Background

In the context of mental health, connectedness is both crucial and complex. For some people, intersubjectivity itself is perceived as dangerous, such that relationships threaten to engulf or annihilate the self (Lysaker, Johannesen, & Lysaker, 2005). Psychosocial development can be disrupted by the onset of disorders, curtailing experience of close relationships outside of the family (e.g. Macdonald, Sauer, Howie & Albiston, 2005). Relationships can be perceived as ‘risky’ and frightening (Dorahy et al., 2013; Redmond, Larkin & Harrop, 2010), and stigmatisation and isolation is commonplace (Pilgrim et al., 2009). Interpersonal difficulties are exacerbated by the increased likelihood of trauma, abuse and adversity in early life (Mackrell & Lavender, 2004). Consequently, people with long-term mental health problems often rely heavily on family (e.g. Randolph, 1998), with whom they may have complex relationships.

The therapeutic relationship is known to be significant for recovery, and positive connections are part of successful long-term therapy (Haskayne & Larkin, 2013). Belonging, safety, openness, participation and empowerment are the quintessential components of a therapeutic environment (Haigh 2013; Pearce & Pickard, 2012). Unfortunately, acute wards for those in most distress are perceived as frightening and non-therapeutic, with impersonal care (Fenton, Larkin, Boden et al., 2014). Low staff morale, high staff turnover, and the ‘revolving door’ phenomenon undermine the provision of consistent and empathic relationships (Haigh, 2002). The socio-political climate and the “independence imperative” (Taylor, 2013, p248) mean service-users have fewer opportunities to form secure attachments. The significance of relatedness for mental illness and health needs revisiting.

This project will develop an interdisciplinary, conceptual framework addressing:

Relationships with family and peers can seemingly create, maintain, and ameliorate mental distress. It is unclear which relational factors are implicated in which processes. Can a relationship be both good and bad for mental health?

Periods of distress and hospitalisation disrupt relational networks, and service-users with enduring difficulties are known to have smaller social networks, yet, with the greater inclusion of informal carers, the burden of care increasingly falls on non-professionals. Is a real ‘distributed recovery’ possible in the current context?

In mental healthcare, open-ended ‘care’ may involve dependency, yet socio-politically extended periods of ‘dependence’ can be positioned as ‘malingering’ by a discourse of ‘austerity’ that attributes blame to the margins. Independence and self-support are prized. Differing needs in mental health mean flexible notions of care and in/dependency are needed – how can care exist where dependency is disallowed?

Findings will be shared at a public event exploring what exactly is, and what ethically and clinically ought to be, the role of relationships in adult mental healthcare? The therapeutic relationship is the intervention in mental health – yet the current UK system is individualistic. How do agendas including ‘social recovery’, ‘relational security’, and the inclusion of informal carers sit alongside the practical, ethical and conceptual role of relationships?

Theoretical Novelty

As relatedness is central to human experience it seems meaningless to construct a conceptual account of the interplay between selves and identities in the mental healthcare system without making experiential analysis central to the project. Our conceptual work will therefore begin with a detailed, idiographic examination of case material. By ‘front-loading’ (Gallagher, 2003) our project with careful attention to the lived experience in these data, we are developing theory both interdisciplinarily and inductively.

Experiential research of this type, grounded in hermeneutic-phenomenological traditions, focuses on trying to understand the ‘person-in-context’ (Larkin, Watts & Clifton, 2006). This means exploring the multiple dimensions of an individual’s lifeworld, with the aim of accepting, considering, and portraying the phenomena at hand, as they are given to us. Our pilot work (Boden, Iyer, Larkin, in prep) captures the distributed and connected aspects of people’s experience of wellbeing and distress, through examining personal accounts in their full interpersonal context. We aim to ‘get closer’ to these experiences, to understand them as fully as possible (Boden & Eatough, 2014), so as to provide building blocks for interdisciplinary conceptual development.
In the mental health context, the service-users’ voice has historically been silenced, their views rendered invalid, and their individuality negated (Faulkner & Thomas, 2002). By drawing explicitly on case-material, we are foregrounding the service-users’ voices in our conceptual development. Dialoguing with service-users and carers (as well as clinicians and policy makers) at our public event, we will re-engage with these voices and integrate them into refining our conceptual account.

Methodology

We plan to follow a fully integrative model of interdisciplinary working, as described by Berini & Woods (2014). We will create a shared conceptual vocabulary (a ‘we-space’) at each of our workshops, whereby collaborators will learn from each others’ disciplinary perspectives through interaction, and integrating ideas from the ‘bottom up’. Collaborators will be requested to bring case-material for each workshop (e.g. clinical cases, extracts of published memoirs and autobiographies, published qualitative research data, qualitative data from our own previous research projects, plus any other source material deemed relevant or inspiring). In this way we will privilege lived experience as the source of our interdisciplinary interactions. By starting with lived experience, all collaborators will have tangible source material on which to build their specific disciplinary thinking, but this will also provide a shared resource enabling the group to negotiate our interactions and engagements across and within disciplinary boundaries.

We will suggest that different disciplines lead each workshop, in order to shift the dynamics of the group each time we meet, and allow for different collaborators to feel more or less within their ‘comfort zone’ at each session. By the culmination of the project at the public workshop, we will have developed a shared language and shared understanding of the themes at hand, and will present these as an integrated conceptual framework.

Work Plan

Three collaborative workshops will be held over seven months. A public event, which will include presentations from members of the working group, as well as invited speakers, will be held at the end of the project.

April 2015: Planning and administration

June 2015: Workshop one: can a relationship be both good and bad for mental health?

Sept 2015: Workshop two: is ‘distributed recovery’ possible in the current context?

Dec 2015: Workshop three: how can care exist when dependency is disallowed?

Feb 2016: Public workshop – what is, and ought to be, the role of relatedness and relationships in mental health care?

Mar 2016: Finalising paper for submission, writing funding report

There will be three formal outputs:

Members of the research team, plus invited speakers (including non-academics, such as service-users and clinicians) will present papers and take part in discussion at a public event. The aim of this event is to help the group think through the clinical and personal implications of the emerging framework. It is our intention to ensure service-users, carers and clinical staff are present. To this end, we have requested funding to supported carers and service-users to attend.

Boden and Larkin will produce a project blog to report the progress of the project.

Collaborators will submit a jointly authored academic paper, reporting our findings (possibly for an interdisciplinary journal such as Medical Humanities).

Outcome

Firstly, we would seek ways in which we could fully utilise the conceptual framework developed in this project, to extend its reach beyond publication in an interdisciplinary journal. This may be through collaboration with other researchers, clinicians or third sector organisations in order to take forward the clinical implications of our findings. The clinically oriented collaborators in our group (Haskayne, Haigh) may also see opportunities for incorporating or further extending our findings within their settings, and we would envisage the opportunity for continuing our work in this way. Each collaborator may see opportunities within their own disciplines for disseminating findings, and perhaps sharing our interdisciplinary practice with colleagues. We may wish to speak at academic or other conferences, or produce further academic papers.

Longer-term, it is our intention that this project provides a ‘jumping off point’ for further large-scale research. In particular, we will seek to use the conceptual clarity gained in this project to design new empirical studies. These qualitative or mixed-methods studies will allow us to collect tailored accounts of relationship contexts within the field of mental health, according to the priorities that emerge through this project. The project will also provide the opportunity to work with a range of scholars with whom we may wish to seek longer-term collaborations. Similarly the opportunity to work in an interdisciplinary group during this project will have allowed us to utilise a methodological approach that we may seek to take forward into a larger scale project.